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Symptom: Falls

Initial Grading Reminder

CTCAE grading of falling:

Grade 1: Minor with no resultant injuries; intervention not indicated
Grade 2: Symptomatic; noninvasive intervention indicated
Grade 3: Hospitalization indicated

Assessment and Grading

Characterize the symptom (onset, pace)

Ask the patient:

Have you had any issues with falling in the past? Is this a new or worsening symptom? When did it start or get worse? Has it developed gradually or suddenly?

Grade the symptom

Ask the patient:

Have you fallen? Have you injured yourself? Did you hit your head? Was it because you had trouble with your leg/foot or because you were dizzy?

Patient Query Regarding Other Symptoms/Red Flags

Ask the patient:

Are you feeling faint? Do you have muscle weakness/vision issues? Do you have a joint that you can’t put weight on?

Patient Factors to Consider That Affect the Approach to Intervention

Consider the following in individualizing the intervention: Is the patient a good or poor historian? Any language barriers or cognitive deficits? Is the patient reliable (able to carry out treatment recommendations)? Does this patient have alcohol/substance abuse issues? Does the patient have transportation? Is there sufficient caregiver support?

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    Suggested Intervention

    Patients with moderate or worse falling episodes should be seen.

    Patient with any of the red-flag symptoms should be seen immediately.

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    Nursing Assessment of Potential Causes

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    Allergic Reaction to Infusion

    Does the patient have any back pain, itching, flushing, difficulty breathing? Is he/she feeling faint? Does he or she have a fever?

    These symptoms are suggestive of an allergic reaction and the patient should be seen immediately. For patients who had an infusion reaction during the actual infusion, hospitalization is indicated for clinical sequelae

    Differential Diagnosis

    What do you suspect is the cause of falling?

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